Rheumatoid arthritis overview: Difference between revisions
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==Medical Therapy== | ==Medical Therapy== | ||
==Surgical | ==Surgical Therapy== | ||
==Primary prevention== | ==Primary prevention== | ||
Revision as of 20:42, 11 April 2018
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Rheumatoid arthritis (RA) is traditionally considered a chronic, inflammatoryautoimmune disorder that causes the immune system to attack the joints. It is a disabling and painful inflammatory condition, which can lead to substantial loss of mobility due to pain and joint destruction. RA is a systemic disease, often affecting extra-articular tissues throughout the body including the skin, blood vessels, heart, lungs, and muscles.
The name is derived from the Greek word rheumatos which means "flowing", and this initially gave rise to the term 'rheumatic fever', an illness that can follow throat infections and which includes joint pain. The suffix -oid means "resembling", i.e. resembling rheumatic fever. Arthr means "joint" and the suffix -itis, a "condition involving inflammation". Thus, rheumatoid arthritis was a form of joint inflammation that resembled rheumatic fever. Rheumatoid arthritis appears to have been described in paintings more than a century before the first detailed medical description of the condition in 1800 by Landre-Beauvais.[1]
Historical Perspective
Rheumatoid arthritis signs and symptoms are noticed by Augustin Jacob Landre-Beauvais, a resident physician at the Saltpetriere asylum in France, in 1800, He named it as Goutte Asthenique Primitive or Primary Asthenic Gout. The name Rheumatoid arthritis coined by Archibald Garrod in 1890. HLA-DR locus present on chromosome 6 is involved in the pathogenesis of rheumatoid arthritis.
Classification
There is no established system for the classification of rheumatoid arthritis. Depending on the presentation of rheumatoid arthritis, it is classified into typical classic rheumatoid arthritis and palindromic rheumatism. There is a classification criterion for the diagnosis of rheumatoid arthritis according to American College of Rheumatology, it uses 4 parameters such as joint involvement, serology, duration of symptoms and acute phase reactants. If the score is more than 6 it is called as definite rheumatoid arthritis.
Pathophysiology
Rheumatoid arthritis is mediated by the combination of a predisposing genotype upon which genetic factors, environmental and microorganism also contribute resulting in the inflammation and destruction of the synovial membrane. All the factors lead to citrullination or post-translational modifications, the altered peptides bind to MHC protein with shared epitopes which further lead to antigen presentation to T-cells. T-cells further stimulate B-cells and cytokines which leads to cartilage damage. Mutation of human leukocyte antigen (HLA) genes on chromosome 6 is involved in pathogenesis of rheumatoid arthritis. Conditions associated with RA are vasculitis, uveitis, scleritis, peripheral ulcerative keratitis, interstitial fibrosis, pulmonary nodules, bronchiolitis obliterans, organizing pneumonia, venous thromboembolism, pericarditis, myocarditis, congestive heart failure, atrial fibrillation, sjogren's syndrome, felty's syndrome.
Causes
Cause of rheumatoid arthritis is idiopathic but genetic like HLA-DR4 cluster, environmental like smoking, hormonal like hyperprolactinemia, immunologic, infectious factors like mycoplasma, epstein-Barr virus (EBV), rubella virus, porphyromonas gingivalis, socioeconomic, psychological, and lifestyle factors such as obesity play important role in the development of rheumatoid arthritis.
Differentiating Rheumatoid Arthritis from other Diseases
Epidemiology and Demographics
The incidence of rheumatoid arthritis is approximately 40 per 100,000 individuals worldwide. The prevalence of rheumatoid arthritis is approximately 1 percent in Caucasians per 100,000 individuals worldwide.The peak onset of the disease is between the age of 50 and 75 year. Women are three times more commonly affected by rheumatoid arthritis than men. Mortality rate of rheumatoid arthritis is approximately 10%.
Risk Factors
Common risk factors in the development of rheumatoid arthritis are the family history of RA, cigarette smoking, race like more prevalent in Native Americans, strongly associated with Major histocompatibility complex (MHC) class II antigen HLA-DR4 and patient with silica and asbestos exposure. Less common risk factors are obesity and high consumption of red meat.
Screening
According to the American College of Rheumatology Guideline, screening for rheumatoid arthritis is not recommended.
Natural History, Complications and Prognosis
Diagnosis
History and Symptoms
Patients with rheumatoid arthritis may have a positive history of the family history of RA, history of smoking and other autoimmune disease. Common symptoms of rheumatoid arthritis are joint pain of small joints of the hands, wrist, and forefoot, joint swelling, morning joint stiffness classically lasting for more than an hour, decreased grip strength, generalized aching, and fatigue, weight loss, depression. Less common symptoms are tingling and numbness in the arm and weakness in the arm.
Physical Examination
Laboratory findings
Laboratory tests used to diagnose rheumatoid arthritis are complete blood count with differentials, erythrocyte sedimentation rate, CRP, Renal function test, LFT and antibodies such as rheumatoid factor, anti-CCP and anti MCV.
X-ray
ECG
There are no ECG findings associated with rheumatoid arthritis. An ECG may be helpful in the diagnosis of pericarditis associated with rheumatoid arthritis. Findings of pericarditis are diffuse ST-segment elevation and PR segment depression.
Ultrasound
Ultrasound is helpful in the diagnosis of rheumatoid arthritis. Findings on an ultrasound suggestive of rheumatoid arthritis are tenosynovitis, bursitis, baker's cyst and inflammation of synovium. Therapeutic use of ultrasound are guidance of corticosteroid injection in the joint and fluid aspiration from the joint effusion.
CT
CT scan is a useful non-invasive test used to diagnose the complications of rheumatoid arthritis such as subluxation of the alanto-axial joint. It is also used in the presurgical assessment of neurological symptoms.
MRI
MRI is helpful in the diagnosis of early and subacute rheumatoid arthritis. Findings on MRI diagnostic of rheumatoid arthritis are synovial hyperemia, synovial hyperplasia, pannus, subchondral cysts, erosions, effusion of joints and bone marrow edema.
Treatment
Medical Therapy
Surgical Therapy
Primary prevention
Effective measures for the primary prevention of rheumatoid arthritis are patient education, exercise, physical and occupational therapy and cognitive behavioral therapies.